U.S. patent application number 11/326885 was filed with the patent office on 2006-08-31 for surfactant treatment regimen.
Invention is credited to Carlos Guardia, Anthony Killian, Christopher Schaber, Robert Segal.
Application Number | 20060194728 11/326885 |
Document ID | / |
Family ID | 36169079 |
Filed Date | 2006-08-31 |
United States Patent
Application |
20060194728 |
Kind Code |
A1 |
Killian; Anthony ; et
al. |
August 31, 2006 |
Surfactant treatment regimen
Abstract
Regimens for the therapeutic or prophylactic administration of
pulmonary surfactant to infants exhibiting or at risk of developing
bronchopulmonary dysplasia are disclosed.
Inventors: |
Killian; Anthony; (Easton,
PA) ; Schaber; Christopher; (Columbus, NJ) ;
Segal; Robert; (Gwynedd Valley, PA) ; Guardia;
Carlos; (Philadelphia, PA) |
Correspondence
Address: |
WOODCOCK WASHBURN LLP
ONE LIBERTY PLACE, 46TH FLOOR
1650 MARKET STREET
PHILADELPHIA
PA
19103
US
|
Family ID: |
36169079 |
Appl. No.: |
11/326885 |
Filed: |
January 6, 2006 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
60641805 |
Jan 6, 2005 |
|
|
|
Current U.S.
Class: |
514/120 ;
514/1.5; 514/12.2; 514/12.4; 514/15.1; 514/15.5; 514/15.7; 514/2.3;
514/2.4 |
Current CPC
Class: |
A61K 33/00 20130101;
A61K 38/395 20130101; A61K 45/06 20130101; A61K 31/00 20130101;
A61K 31/00 20130101; A61K 2300/00 20130101; A61K 2300/00 20130101;
A61K 38/00 20130101; A61P 11/00 20180101; A61K 33/00 20130101; A61P
11/08 20180101 |
Class at
Publication: |
514/012 |
International
Class: |
A61K 38/17 20060101
A61K038/17 |
Claims
1. A method for treating or preventing bronchopulmonary dysplasia
in an infant treated with pulmonary surfactant for respiratory
distress syndrome, the method comprising: following the treatment
for respiratory distress syndrome with pulmonary surfactant,
administering pulmonary surfactant to the infant in an amount and
for a time effective to treat or prevent the bronchopulmonary
dysplasia.
2. The method of claim 1 wherein the administering is initiated at
the next dosage interval following completion of the treatment for
respiratory distress syndrome with pulmonary surfactant.
3. The method of claim 1 wherein the administering is initiated at
day 3 of life of the infant.
4. The method of claim 1 wherein the administering is continued
through at least 36 weeks post-menstrual age of the infant.
5. The method of claim 1 wherein the administering is continued
through at least 28 days post-natal age of the infant.
6. The method of claim 1 wherein the administering is continued
through at least day 14 of life of the infant.
7. The method of claim 1 wherein the administering is continued
through at least day 18 of life of the infant.
8. The method of claim 3 wherein the administering is initiated at
day 3 of life of the infant and is continued through at least day
14 of life of the infant
9. The method of claim 1 wherein the administering is initiated
anytime from day 3 to day 14 of life of the infant.
10. The method of claim 9 wherein the administering is initiated
anytime from day 3 to day 10 of life of the infant.
11. The method of claim 1 wherein the method comprises preventing
bronchopulmonary dysplasia.
12. The method of claim 1 wherein administration is by endotracheal
administration.
13. The method of claim 1 wherein administration is by
inhalation.
14. The method of claim 1 wherein the administering is accompanied
by another respiratory therapy.
15. The method of claim 14 wherein the other respiratory therapy is
conventional ventilation, high frequency ventilation or continuous
positive airway pressure.
16. The method of claim 14 wherein the other respiratory therapy is
administration of one or more therapeutic agents.
17. The method of claim 16 wherein the other therapeutic agents are
nitric oxide, steroids, antioxidants, vitamins, vitamin
derivatives, reactive oxygen scavengers, bronchodilators,
diuretics, antimicrobial agents, anti-infective agents,
anti-hypertensive agents or anti-inflammatory agents.
18. The method of claim 1 comprising administering a synthetic
pulmonary surfactant.
19. The method of claim 18 wherein the synthetic pulmonary
surfactant comprises a peptide having SEQ ID NO:1.
20. A method for treating or preventing bronchopulmonary dysplasia
in an infant requiring respiratory support, the method comprising
administering pulmonary surfactant to the infant in an amount and
for a time effective to treat or prevent the bronchopulmonary
dysplasia.
21. The method of claim 20 wherein the method comprises preventing
bronchopulmonary dysplasia.
22. The method of claim 20 wherein the treatment with pulmonary
surfactant is administered until the infant no longer requires
respiratory support.
23. The method of claim 20 wherein the administering is initiated
at or after day 1 of life of the infant and is continued through at
least 36 weeks post-menstrual age of the infant.
24. The method of claim 20 wherein the administering is initiated
at or after day 1 of life of the infant and continued through at
least 28 days post-natal age of the infant.
25. The method of claim 20 wherein the administering is initiated
at day 1 of life of the infant.
26. The method of claim 20 wherein the administering is initiated
at day 3 of life of the infant.
27. The method of claim 20 wherein the administering is initiated
before the infant has been diagnosed with BPD and the infant is
treated with pulmonary surfactant at least once after day 2 of life
of the infant.
28. The method of claim 27 wherein the infant is treated with
pulmonary surfactant at least once after day 3 of life of the
infant.
29. The method of claim 27 wherein the administering is initiated
at day 1 of life of the infant.
30. The method of claim 29 wherein the administering is continued
through at least day 10 of life of the infant.
31. The method of claim 29 wherein the administering is continued
through at least day 14 of life of the infant.
32. The method of claim 27 wherein treatment is initiated at day 2
of life the infant.
33. The method of claim 32 wherein treatment is continued through
at least day 14 of life of the infant.
34. The method of claim 27 wherein the administering is initiated
anytime from day 3 to day 18 of life of the infant.
35. The method of claim 20 wherein the infant does not exhibit
respiratory distress syndrome.
36. The method of claim 20 wherein the infant exhibits respiratory
distress syndrome.
37. The method of claim 36 wherein pulmonary surfactant is
administered to the infant following the episode of respiratory
distress syndrome.
38. The method of claim 36 wherein the administering is initiated
at or after day 1 of life of the infant and is continued through at
least 36 weeks post-menstrual age of the infant.
39. The method of claim 36 wherein the administering is initiated
at or after day 1 of life of the infant and continued through at
least 28 days post-natal age of the infant.
40. The method of claim 36 wherein the administering is initiated
at day 1 of life of the infant.
41. The method of claim 36 wherein the administering is initiated
at day 3 of life of the infant.
42. The method of claim 36 wherein the administering is initiated
before the infant has been diagnosed with BPD and the infant is
treated with pulmonary surfactant at least once after day 2 of life
of the infant.
43. The method of claim 42 wherein the infant is treated with
pulmonary surfactant at least once after day 3 of life of the
infant
44. The method of claim 42 wherein the administering is initiated
at day 1 of life of the infant.
45. The method of claim 44 wherein the administering is continued
through at least day 10 of life of the infant.
46. The method of claim 44 wherein the administering is continued
through at least day 14 of life of the infant.
47. The method of claim 42 wherein treatment is initiated at day 2
of life the infant.
48. The method of claim 47 wherein treatment is continued through
at least day 14 of life of the infant.
49. The method of claim 42 wherein the administering is initiated
anytime from day 3 to day 18 of life of the infant.
50. The method of claim 20 wherein administration is by
endotracheal administration.
51. The method of claim 20 wherein administration is by
inhalation.
52. The method of claim 20 wherein the administering is accompanied
by another respiratory therapy.
53. The method of claim 52 wherein the other respiratory therapy is
conventional ventilation, high frequency ventilation or continuous
positive airway pressure.
54. The method of claim 52 wherein the other respiratory therapy is
administration of one or more therapeutic agents.
55. The method of claim 54 wherein the other therapeutic agents are
nitric oxide, steroids, antioxidants, vitamins, vitamin
derivatives, reactive oxygen scavengers, bronchodilators,
diuretics, antimicrobial agents, anti-infective agents,
anti-hypertensive agents or anti-inflammatory agents.
56. The method of claim 20 comprising administering a synthetic
pulmonary surfactant.
57. The method of claim 56 wherein the synthetic pulmonary
surfactant comprises a peptide having SEQ ID NO: 1.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims benefit under 35 U.S.C. .sctn.119(e)
to application Ser. No. 60/641,805 filed Jan. 6, 2005, the
disclosure of which is incorporated by reference in its
entirety.
FIELD
[0002] This invention relates to the treatment of pulmonary
disorders. In particular, regimens for the treatment or prevention
of bronchopulmonary dysplasia and related disorders are provided,
featuring the use of pulmonary surfactants.
BACKGROUND
[0003] Various patents, patent publications and scientific articles
may be referred to throughout the specification. The contents of
each of these documents are incorporated by reference herein, in
their entireties.
[0004] Natural pulmonary surfactants (PS) are protein/lipid
compositions that are produced naturally in the lungs and are
critical to the lungs' ability to absorb oxygen. They cover the
entire alveolar surface of the lungs and the terminal conducting
airways leading to the alveoli. Surfactants facilitate respiration
by continually modifying the surface tension of the fluid normally
present within the alveoli. In the absence of sufficient
surfactant, or should the surfactant degrade, the alveoli tend to
collapse and the lungs do not absorb sufficient oxygen. By lowering
the surface tension of the terminal conducting airways, surfactant
maintains patency, i.e., keeps airways open. Loss of patency leads
to loss of patency obstruction of the airway and compromised
pulmonary function. Human surfactants primarily contain:
phospholipids, the major one being dipalmitoyl phosphatidyl-choline
(DPPC), and four surfactant polypeptides, A, B, C and D with
surfactant protein B (SP-B) being the most essential for
respiratory function. Natural and synthetic pulmonary surfactants
are commonly used to treat respiratory distress syndrome in
premature infants shortly after birth.
[0005] Bronchopulmonary dysplasia (BPD or BD), also referred to as
chronic lung disease (CLD), is a common, occasionally life
threatening, lung disease typically occurring in premature infants
who survive respiratory distress syndrome (RDS) and other
complications of prematurity. With the near universal adoption of
antenatal steroids and post-natal use of exogenous lung
surfactants, large numbers of at-risk low birth weight infants now
survive the acute lung disease of prematurity only to develop
chronic lung disease. Prior to the widespread use of synthetic or
animal derived surfactants, BPD was histologically characterized by
airway injury and fibrosis. Since the advent of surfactant
replacement therapy, infants appear to experience less airway and
fibrotic involvement than described in earlier reports but have
abnormalities in alveolarization and vascularization. The change in
the nature of the condition has led neonatologists to refer to a
"new BPD". BPD can also develop in term infants who require
respiratory support at birth or soon thereafter.
[0006] Surfactant therapy has decreased the frequency with which
larger, moderately premature infants develop the disease, but the
survival benefits of surfactant in extremely premature infants has
resulted in a shift in the incidence of BPD toward smaller, more
premature babies. Post-natal steroids in anti-inflammatory doses
are known to modestly decrease the physiologic consequences of BPD,
but at the expense of neuro-developmental outcomes. Further,
steroids may decrease alveolarization. Vitamin A derivatives
stimulate alveolarization in animals, but clinical results have
been modest. Despite an intriguing rationale, antioxidants have
proven to be of little value. Whether inhaled nitric oxide will
decrease the likelihood of BPD in very low birth weight infants
awaits the outcome of ongoing clinical trials.
[0007] Causes of BPD or CLD are probably multi-factorial. However,
the pathophysiologic antecedents and consequences of BPD may
suggest a new approach to prevention with drugs already in clinical
use. Decreased lung compliance as a consequence of initially mild
pulmonary edema has been shown to correlate with subsequent
development of BPD. Neutrophil migration to the lung increases in
the presence of pulmonary edema and hyperoxia. When these cells are
activated, they release proteases and inflammatory mediators
including oxidants that can further injure the lung. These events
degrade pulmonary function necessitating mechanical ventilation for
many infants initially weaned from the ventilator and increasing
ventilator requirements for those never able to wean. Surfactant is
itself a target of proteases, oxidant species and small molecule
mediators and can be inactivated by many plasma proteins found in
bronchoalveolar fluid in the presence of capillary leak.
[0008] Treatments to prevent or ameliorate BPD and related
pulmonary disorders are needed. The present invention is directed
to this and other important needs.
BRIEF SUMMARY
[0009] One aspect of the invention features a method for treating
or preventing BPD in an infant treated with pulmonary surfactant
for respiratory distress syndrome ("RDS"). Following the treatment
for respiratory distress syndrome with pulmonary surfactant,
pulmonary surfactant is administered to the infant in an amount and
for a time effective to treat or prevent the BPD. Typically,
administration of the pulmonary surfactant for BPD is initiated
after the treatment of the respiratory distress syndrome with
pulmonary surfactant, for instance, at the next dosage interval
following completion of the treatment for RDS, at day 3 of life of
the infant, or whenever the treatment for RDS is completed. In
certain embodiments, administration of the pulmonary surfactant is
continued through at least 36 weeks post-menstrual age ("PMA") of
the infant or alternatively through at least 28 days post-natal age
of the infant. In certain embodiments, administration of the
pulmonary surfactant is continued through at least day 14 or day 18
of life of the infant. In certain embodiments, treatment is
initiated anytime from day 3 of life of the infant to day 10 or
even later, e.g., day 14 or 18 of life of the infant or later.
[0010] Another aspect of the invention features a method for
treating or preventing BPD in an infant requiring respiratory
support. The pulmonary surfactant is administered to the infant in
an amount and for a time effective to treat or prevent the BPD. In
certain embodiments, the PS is administered until the infant no
longer requires respiratory support. In certain embodiments, the PS
is administered at or after day 1 of life of the infant and is
continued through at least 36 weeks PMA or alternatively through at
least 28 days post-natal age of the infant. In certain embodiments,
the administering is initiated at day 1 of life of the infant or at
day 3 of life of the infant. In certain embodiments, the
administering is initiated before the infant has been diagnosed
with BPD and the infant is treated with pulmonary surfactant at
least once after day 2, 3, 4, 5, 6, 7, 8, 9, or 10 of life of the
infant. In certain embodiments, the administering is initiated at
day 1 of life of the infant or at day 2, of life of the infant and
the infant is treated with pulmonary surfactant at least once after
day 2, 3, 4, 5, 6, 7, 8, 9, or 10 of life of the infant. In some of
these embodiments, treatment is continued through at least day 10,
day 14, or day 18 of life of the infant. In some of these
embodiments, administration of PS is initiated anytime from day 3
to day 18, day 3 to day 14, or day 3 to day 10 of life of the
infant. The infant requiring respiratory support may or may not
exhibit respiratory distress syndrome.
[0011] Methods of administering pulmonary surfactant to an infant
are known in the art. In certain embodiments, administration is by
endotracheal administration. In other embodiments, administration
is by aerosolization and inhalation. The term "inhalation"
includes, for example, both inhalation of a dry powder and
inhalation of a wet aerosol.
[0012] In certain embodiments, the aforementioned treatment
protocol is accompanied by another respiratory therapy, such as
mechanical ventilation, continuous positive airway pressure (CPAP)
including nasal CPAP (nCPAP) or administration of other therapeutic
agents.
[0013] In a preferred embodiment, the method comprises
administering a synthetic pulmonary surfactant. Particularly
preferred is a pulmonary surfactant that contains a peptide having
a sequence of SEQ ID NO: 1.
[0014] Other features and advantages of the invention will be
understood from the detailed description and examples that
follow.
DETAILED DESCRIPTION
[0015] Unless otherwise specified, all medical procedures described
or referred to herein are performed in accordance with current
standards of care understood by physicians and/or other healthcare
practitioners.
[0016] It is also to be understood that the terminology used herein
is for the purpose of describing particular embodiments only, and
is not intended to be limiting. As used in this specification and
the appended claims, the singular forms "a", "an", and "the"
include plural referents unless the content clearly dictates
otherwise. Thus, for example, reference to "a peptide" includes a
combination of two or more peptides, and the like.
[0017] "About" as used herein when referring to a measurable value
such as an amount, a temporal duration, and the like, is meant to
encompass variations of .+-.20% or .+-.10%, more preferably .+-.5%,
even more preferably .+-.1%, and still more preferably .+-.0.1%
from the specified value, as such variations are appropriate to
perform the disclosed methods.
[0018] Unless defined otherwise, all technical and scientific terms
used herein have the same meaning as commonly understood by one of
ordinary skill in the art to which the invention pertains. Although
any methods and materials similar or equivalent to those described
herein can be used in the practice for testing of the present
invention, the preferred materials and methods are described
herein. In describing and claiming the present invention, the
following terminology will be used.
[0019] "Polypeptide," "peptide" "peptoids" and "protein" are used
interchangeably to refer to a polymer of amino acid residues. The
terms apply to amino acid polymers in which one or more amino acid
residue is an artificial chemical mimetic of a corresponding
naturally occurring amino acid, as well as to naturally occurring
amino acid polymers and non-naturally occurring amino acid polymer.
Amino acid mimetics refers to chemical compounds that have a
structure that is different from the general chemical structure of
an amino acid, but that functions in a manner similar to a
naturally occurring amino acid. Non-natural residues are well
described in the scientific and patent literature; a few exemplary
non-natural compositions useful as mimetics of natural amino acid
residues and guidelines are described below. Mimetics of aromatic
amino acids can be generated, for example, by replacing by, e.g.,
D- or L-naphylalanine; D- or L-phenylglycine; D- or L-2
thieneylalanine; D- or L-1, -2,3-, or 4-pyreneylalanine; D- or L-3
thieneylalanine; D- or L-(2-pyridinyl)-alanine; D- or
L-(3-pyridinyl)-alanine; D- or L-(2-pyrazinyl)-alanine; D- or
L-(4-isopropyl)-phenylglycine; D-(trifluoromethyl)-phenylglycine;
D-(trifluoromethyl)-phenylalanine; D-p-fluoro-phenylalanine; D- or
L-p-biphenylphenylalanine; K- or L-p-methoxy-biphenylphenylalanine;
D- or L-2-indole(alkyl)alanines; and, D- or L-alkylainines, where
alkyl can be substituted or unsubstituted methyl, ethyl, propyl,
hexyl, butyl, pentyl, isopropyl, iso-butyl, sec-isotyl, iso-pentyl,
or a non-acidic amino acids. Aromatic rings of a non-natural amino
acid include, e.g., thiazolyl, thiophenyl, pyrazolyl,
benzimidazolyl, naphthyl, furanyl, pyrrolyl, and pyridyl aromatic
rings.
[0020] "Peptide" includes peptides which are conservative
variations of those peptides specifically exemplified herein.
"Conservative variation" as used herein denotes the replacement of
an amino acid residue by another, biologically similar residue.
Examples of conservative variations include, but are not limited
to, the substitution of one hydrophobic residue such as isoleucine,
valine, leucine, alanine, cysteine, glycine, phenylalanine,
proline, tryptophan, tyrosine, norleucine or methionine for
another, or the substitution of one polar residue for another, such
as the substitution of arginine for lysine, glutamic for aspartic
acids, or glutamine for asparagine, and the like. Neutral
hydrophilic amino acids which can be substituted for one another
include asparagine, glutamine, serine and threonine. "Conservative
variation" also includes the use of a substituted amino acid in
place of an unsubstituted parent amino acid provided that
antibodies raised to the substituted polypeptide also immunoreact
with the unsubstituted polypeptide. Such conservative substitutions
are within the definition of the classes of the peptides of the
invention. "Cationic" as used herein refers to any peptide that
possesses a net positive charge at pH 7.4. The biological activity
of the peptides can be determined by standard methods known to
those of skill in the art and described herein.
[0021] Peptides of the invention can be synthesized by methods
known in the art. For example, in certain embodiments, commonly
used methods such as t-BOC or FMOC protection of alpha-amino groups
can be used. Both methods involve stepwise syntheses whereby a
single amino acid is added at each step starting from the C
terminus of the peptide (See, Coligan et al., Current Protocols in
Immunology, Wiley Interscience, 1991, Unit 9). Peptides of the
invention can be synthesized, for example, by the well known solid
phase peptide synthesis methods described in Merrifield, J. Am.
Chem. Soc. 85: 2149, 1962, and Stewart and Young, 1969, Solid Phase
Peptides Synthesis, pp. 27-62, using a
copoly(styrene-divinylbenzene) containing 0.1-1.0 mMol amines/g
polymer. On completion of chemical synthesis, the peptides can be
deprotected and cleaved from the polymer by treatment with liquid
HF-10% anisole for about 1/4-1 hours at 0.degree. C. After
evaporation of the reagents, the peptides are extracted from the
polymer with 1% acetic acid solution which is then lyophilized to
yield the crude material. This can normally be purified by such
techniques as gel filtration on Sephadex G-15 using 5% acetic acid
as a solvent. Lyophilization of appropriate fractions of the column
will yield the homogeneous peptide or peptide derivatives, which
can then be characterized by such standard techniques as amino acid
analysis, thin layer chromatography, high performance liquid
chromatography, ultraviolet absorption spectroscopy, molar
rotation, solubility, and quantitated by the solid phase Edman
degradation.
[0022] "Recombinant" when used with reference to a protein
indicates that the protein has been modified by the introduction of
a heterologous nucleic acid or protein or the alteration of a
native nucleic acid or protein.
[0023] For the purposes of present invention, BPD is diagnosed at
28 days of age or thereabout, 36 weeks PMA or thereabout, or as set
forth in Table 1 below. An infant that either remains on mechanical
ventilation or requires supplemental oxygen in order to maintain
oxygen saturation levels ("SaO.sub.2") greater than or equal to 90%
(with the exception of infants requiring supplemental oxygen during
feedings) at 36 weeks PMA or at 28 days of age is said to have BPD.
Generally, chest x-rays will also be performed for infants at 28
days of age in order to confirm the BPD diagnosis. The x-ray of
lungs with BPD often have a bubbly, sponge-like appearance. X-rays
are diagnostic tests which use invisible electromagnetic energy
beams to produce images of internal tissues, bones, and organs onto
film.
[0024] Alternatively, BPD can be diagnosed using the criteria set
forth in Table 1 below from Jobe and Bancalari, Am J Respir Crit
Care Med, 2001, 163:1723-1729, incorporated herein by reference in
its entirety for all purposes. TABLE-US-00001 TABLE 1 Gestational
Age <32 weeks .gtoreq.32 weeks Time point 36 weeks PMA or
discharge >28 days but <56 days of assessment to home,
whichever comes post-natal age or dis- first charge to home, which-
ever comes first Infants have already been Infants have already
been treated with oxygen >21% treated with oxygen for at least
28 days plus >21% for at least 28 days plus Mild BPD Breathing
room air at 36 Breathing room air by 56 weeks PMA or discharge,
days post-natal age or whichever comes first discharge, whichever
comes first Moderate BPD Need for <30% oxygen at 36 Need for
<30% oxygen weeks PMA or discharge, at 56 days post-natal age
whichever comes first or discharge, whichever comes first Severe
BPD Need for .gtoreq.30% oxygen Need for .gtoreq.30% oxygen and/or
positive pressure (e.g., and/or positive pressure PPV or NCPAPA) at
36 (e.g., PPV or NCPAPA) weeks PMA or discharge, at 56 days
post-natal age whichever comes first or discharge, whichever comes
first
[0025] Infants treated with oxygen >21% and/or positive pressure
for nonrespiratory disease (e.g., central apnea or diaphragrnatic
paralysis) as provided in Table 1 do not have BPD unless they also
develop parenchymal lung disease and exhibit clinical features of
respiratory distress. A day of treatment with oxygen >21% means
that the infant received oxygen >21 % for more than 12 hours on
that day. Treatment with oxygen >21% and/or positive pressure at
36 weeks PMA, or at 56 days post-natal age or discharge, should not
reflect an "acute" event, but should rather reflect the infant's
usual daily therapy for several days preceding and following 36
weeks PMA, 56 days post-natal age, or discharge.
[0026] For the purposes of present invention, "Respiratory Distress
Syndrome" is defined at being present in an infant at 24 hours of
age with a need for a fraction of inspired oxygen
("FiO.sub.2").gtoreq.0.30 combined with the demonstration of a
reticulogranular pattern on a chest radiograph obtained between 20
and 28 hours of age.
[0027] "Supplemental oxygen" refers to any requirement for
additional oxygen to maintain oxygen saturation levels >90%.
This can include mechanical ventilation and/or CPAP if supplemental
oxygen (.gtoreq.21% FiO.sub.2) is being given.
[0028] "Infant" includes neonatal infants. Typically a neonatal
infant is an infant born prematurely or otherwise, under 4 weeks
old. For the purposes used herein, infants are under 2 years
old.
[0029] "Respiratory support" includes any intervention that treats
respiratory illness including, for example, the administration of
supplemental oxygen, mechanical ventilation, CPAP, albuterol
treatment, and the like.
[0030] "Treating" refers to any indicia of success in the treatment
or amelioration of the disease or condition, e.g., BPD. Treatment
at Day 1 (or DOL 1) is the day on which Time 0 (time of birth)
occurs and DOL 2, 3, and so on, begin at 00:00 (midnight) each
subsequent day following Time 0.
[0031] "Preventing" refers to the prevention of the disease or
condition, e.g., BPD, in the patient. For example, if an infant
exhibiting respiratory distress syndrome, or requiring any form of
respiratory support at birth, is treated with the methods of the
present invention and is not later diagnosed with BPD, e.g., at 28
days of age or at 36 weeks PMA, it will be understood that BPD has
been prevented in that infant.
[0032] "Surfactant activity" refers to the ability of any
substance, such as an organic molecule, protein or polypeptide,
either alone or in combination with other molecules, to lower
surface tension at an air/water interface. The measurement can be
made with a Wilhelmy Balance or pulsating bubble surfactometer by
an in vitro assay. See, for example King et al, Am. J. Physiol.
1972, 223:715-726, or Enhorning, J. Appl. Physiol., 1977,
43:198-203, each of which is incorporated herein by reference in
its entirety. Briefly, the Enhorning Surfactometer (Surfactometer
International, Toronto, Ontario) measures the pressure gradient
(.delta.P) across a liquid-air interface of a bubble that pulsates
at a rate of 20 cycles/min between a maximal (0.55 mm) and minimal
(0.4 mm) radius. The bubble, formed in a 37.degree. C.,
water-enclosed, 20-.mu.l sample chamber, is monitored through a
microscopic optic while the pressure changes are recorded on a
strip chart recorder calibrated for 0 and -2 cm H.sub.2O. In
addition, in vivo measurements of increases of compliance or
airflow at a given pressure of air entering the lung can be readily
made, such as in the assay of Robertson, Lung, 1980, 158:57-68,
incorporated herein by reference in its entirety. In this assay,
the sample to be assessed is administered through an endotracheal
tube to fetal rabbits or lambs delivered prematurely by Caesarian
section. (These "preemies" lack their own PS, and are supported on
a ventilator.) Measurements of lung compliance, blood gases and
ventilator pressure provide indices of activity. In vitro assays of
surfactant activity, which is assessed as the ability to lower the
surface tension of a pulsating bubble, and in vivo assays utilizing
fetal rabbits is described in detail by Revak et al, Am. Rev.
Respir. Dis., 1986, 134:1258-1265.
[0033] In one aspect, the invention contemplates the therapeutic or
prophylactic administration of pulmonary surfactant (PS) to infants
exhibiting or at risk of developing bronchopulmonary dysplasia (BD
or BPD). In one embodiment, PS administration is initiated in an
infant exhibiting respiratory distress syndrome, following
treatment of such syndrome with pulmonary surfactant or by another
means (e.g., ventilation) or a combination thereof. Typically,
infant RDS is treated via PS therapy within the first few hours to
one or two days after birth. In the methods of the invention,
administration of PS for the treatment or prevention of BPD is
initiated following the RDS treatment, e.g., at day 2, 3, 4, 5, 6,
7, 8, 9, 10, 11, 12, 13, or 14 of life or thereabout, or whenever
the treatment for RDS is completed. In certain embodiments, the
infant will be treated with pulmonary surfactant at the next dosage
interval appropriate for such treatment after completion of RDS
treatment. For example, in some embodiments, where PS is
administered as a liquid by intratracheal instillation, treatment
with PS for BPD will be about 6 hours following the last treatment
of PS for RDS. A clinician will be able to determine, based on
administration protocols known in the art, when dosage of PS for
the treatment of BPD should be initiated.
[0034] In certain embodiments, the infant may not receive PS
therapy for RDS, but nonetheless can be administered PS to treat or
prevent BPD, in accordance with the present invention. In certain
embodiments, the treatment with PS will be initiated following the
episode of respiratory distress syndrome. In certain preferred
embodiments, the administering is initiated before the infant has
been diagnosed with BPD and the infant is treated with pulmonary
surfactant at least once after day 2, 3, 4, 5, 6, 7, 8, 9, or 10 of
life of the infant. The administration of PS can be initiated, for
example, at or after day 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14
of life or therabout of the infant. Methods of diagnosing
respiratory distress syndrome are known in the art and are thus not
described herein in detail.
[0035] In certain embodiments, infants to be treated with the
present methods require respiratory support but do not necessarily
exhibit respiratory distress syndrome. These infants either have
not been diagnosed with RDS or have not been treated with PS for
RDS. In these infants, treatment can be initiated as soon as it is
recognized that these infants require respiratory support. In
certain embodiments, this will be at day 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, or 14 of life or thereabout, or between about day 3
to day 10 of the life of the infant. In certain embodiments, this
can be later than day 10 of the life of the infant, e.g., day 14,
day 18 or later.
[0036] PS therapy can be provided concomitantly with other forms of
respiratory support. Typically, the PS therapy is initiated before
the infant has been diagnosed with BPD. In certain embodiments, the
present methods will prevent the infant from developing BPD.
[0037] Treatment is continued for a period of time deemed by a
physician or other medical practitioner as appropriate to achieve a
therapeutic or prophylactic effect. Treatment can be continued, for
example, until the infant no longer requires respiratory support or
even longer. Typically, treatment is continued for one to two
weeks, e.g., until day 14 or day 18 of the infant's life or
thereabout. However, the duration of treatment can be shorter,
e.g., one week, or longer, e.g., extending three or more weeks, or
until the infant is discharged from neonatal intensive care or from
the hospital. For example, treatment can be continued through at
least 36 weeks PMA of the infant or at least 28 days post-natal age
of the infant. In certain embodiments, wherein the infant does not
exhibit respiratory distress syndrome at birth but, days later,
develops a condition that requires respiratory support, treatment
with PS may not be initiated until well after day 3 of life of the
infant and thus treatment will typically be continued past day 14
or day 18 of the infant's life. In infants born prematurely, for
example, regardless of whether the infant exhibited respiratory
distress syndrome at or near birth, treatment can be continued, for
example, until 36 weeks PMA or even later.
[0038] In various embodiments, the PS is administered periodically
or continuously throughout the treatment period, at dosages and
utilizing protocols in accordance with standard and/or
manufacturer's instructions (see, e.g., Example 1).
[0039] The PS selected for use in the methods of the invention can
be the same as, or different from, the PS utilized for RDS. In one
embodiment, the same PS is used. Any PS currently in use, or
hereafter developed for use in RDS and other pulmonary conditions,
is suitable for use in the present invention.
[0040] In certain aspects, a pulmonary surfactant of the present
invention comprises a cationic peptide that can be derived from
animal sources or synthetically. Exemplary peptides for use herein
include naturally and non-naturally occurring pulmonary surfactant
polypeptides, such as, for example, one or a combination of
animal-derived SP-A, SP-B, SP-C, or SP-D polypeptides; recombinant
SP-A, SP-B, SP-C, or SP-D polypeptides; synthetically derived SP-A,
SP-B, SP-C, or SP-D polypeptides; SP-A, SP-B, SP-C, and SP-D
analogs; SP-A, SP-B, SP-C, and SP-D polypeptide mimics;
conservatively modified variants thereof retaining activity; and
fragments thereof retaining activity. A pulmonary surfactant
polypeptide mimic is generally a polypeptide that is engineered to
mimic the essential attributes of human surfactant protein. In
certain preferred embodiments, the pulmonary surfactant polypeptide
comprises a cationic peptide that consists of at least about 10,
preferably at least 11 amino acid residues, and no more than about
80, more usually fewer than about 35 and preferably fewer than
about 25 amino acid residues.
[0041] Exemplary amino acid sequences of pulmonary surfactant
polypeptides for use herein, methods of isolating them, and
producing them by genetic engineering techniques are known in the
art. See for example, U.S. Pat. Nos. 5,874,406; 5,840,527;
4,918,161; 5,827,825; 6,660,833, 5,006,343; 5,455,227; 5,223,481;
5,753,621; 5,891,844; 4,861,756; 5,272,252; 5,024,95; 5,238,920;
5,302,481; 6,022,955; 5,874,406; 5,840,527; 5,827,825; 6,013,619;
6,660,833; and International Publication Nos, WO8603408 and
WO8904326, the disclosures of each of which are hereby incorporated
by reference in its entirety. A preferred lung surfactant peptide
for use herein is a SP-B or SP-C polypeptide, or polypeptide
mimic.
[0042] A preferred synthetic pulmonary surfactant comprises one or
more phospholipids and a polypeptide, in which the polypeptide,
when admixed with a phospholipid, forms a synthetic pulmonary
surfactant having a surfactant activity greater than the surfactant
activity of the phospholipid alone. A particularly preferred
pulmonary surfactant polypeptide for use herein is a SP-B
polypeptide or polypeptide mimic. SP-B is the protein in natural
pulmonary surfactant known to be the most important surfactant
protein for surface tension lowering and promoting oxygen exchange.
SP-B polypeptide mimics are small hydrophobic polypeptides,
generally less than about 80 amino acids in size. Many SP-B
polypeptide mimics possess a repeating hydrophobic cationic motif.
Like natural SP-B polypeptide, SP-B mimics, preferably, lower
surface tension of the terminal conducting airways and promote
oxygen exchange.
[0043] A preferred SP-B mimetic for use in the present invention is
KL4 peptide, which is a cationic peptide containing repeating
lysine and leucine residues. KL4 is representative of a family of
pulmonary surfactant polypeptide mimetics which are described, for
example, in U.S. Pat. Nos. 5,260,273, 5,164,369, 5,407,914 and
6,613,734, each of which is hereby incorporated by reference in its
entirety and for all purposes. Methods of preparing the KL4 peptide
can be found in U.S. Pat. No. 5,164,369.
[0044] In certain embodiments, pulmonary surfactants polypeptide
mimics refer to polypeptides with an amino acid residue sequence
that has a composite hydrophobicity of less than zero, preferably
less than or equal to -1, more preferably less than or equal to -2.
The composite hydrophobicity value for a peptide is determined by
assigning each amino acid residue in a peptide its corresponding
hydrophilicity value as described in Hopp et al., Proc. Natl. Acad.
Sci. 78: 3824-3829, 1981, which disclosure is incorporated by
reference. For a given peptide, the hydrophobicity values are
summed, the sum representing the composite hydrophobicity value.
These hydrophobic polypeptides typically perform the function of
the hydrophobic region of SP18. Accordingly, in certain
embodiments, the amino acid sequence of the puhnonary surfactant
polypeptide mimic mimics the pattern of hydrophobic and hydrophilic
residues of SP18 and perform the function of the hydrophobic region
of SP18. SP18 is a known lung surfactant apoprotein, more
thoroughly described in Glasser et al., Proc. Natl. Acad. Sci. 84:
4007-4001, 1987, which is hereby incorporated by reference in its
entirety and for all purposes. It should be understood, however,
that polypeptides and other surfactant molecules of the present
invention are not limited to molecules having sequences like that
of native SP18. On the contrary, some preferred surfactant
molecules of the present invention have little resemblance to SP18
with respect to a specific amino acid residue sequence, except that
they have similar surfactant activity and alternating
charged/uncharged (or hydrophobic/hydrophilic) residue
sequences.
[0045] In certain embodiments, exemplary polypeptides for use
herein have alternating hydrophobic and hydrophilic amino acid
residue regions and are characterized as having at least 10 amino
acid residues represented by the formula:
(Z.sub.aU.sub.b).sub.cZ.sub.d Z and U are amino acid residues such
that at each occurrence Z and U are independently selected. Z is a
hydrophilic amino acid residue, preferably selected from the group
consisting of R, D, E and K. U is a hydrophobic amino acid residue,
preferably selected from the group consisting of V, I, L, C, Y, and
F. The letters, "a," "b,", "c" and "d" are numbers which indicate
the number of hydrophilic or hydrophobic residues. The letter "a"
has an average value of about 1 to about 5, preferably about 1 to
about 3. The letter "b" has an average value of about 3 to about
20, preferably about 3 to about 12, most preferably, about 3 to
about 10. The letter "c" is 1 to 10, preferably, 2 to 10, most
preferably 3 to 6. The letter "d" has an average value of about 0
to 3, preferably 1 to 2.
[0046] In certain embodiments, surfactant polypeptides include a
sequence having alternating groupings of amino acid residues as
represented by the formula: (Z.sub.aJ.sub.b).sub.cZ.sub.d wherein Z
is an amino acid residue independently selected from the group
consisting of R, D, E, and K; J is an .alpha.-aminoaliphatic
carboxylic acid; a has an average value of about 1 to about 5; b
has an average value of about 3 to about 20; c is 1 to 10; and d is
0 to 3.
[0047] In certain embodiments, polypeptides of the present
invention have alternating groupings of amino acids residue regions
as represented by the formula: (B.sub.aU.sub.b).sub.cB.sub.d
wherein B is an amino acid residue independently selected from the
group consisting of H, 5-hydroxylysine, 4-hydroxyproline, and
3-hydroxyproline; and U is an amino acid residue independently
selected from the group consisting of V, I, L, C, Y, and F. In one
preferred variation, B is an amino acid derived from collagen and
is preferably selected from the group consisting of
5-hydroxylysine, 4-hydroxyproline, and 3-hydroxyproline; a has an
average value of about 1 to about 5; b has an average value of
about 3 to about 20; c is 1 to 10; and d is 0 to 3.
[0048] In certain embodiments, surfactant polypeptides of the
present invention include a sequence having alternating groupings
of amino acid residues as represented by the formula:
(B.sub.aJ.sub.b).sub.cB.sub.d wherein B is an amino acid residue
independently selected from the group consisting of H,
5-hydroxylysine, 4-hydroxyproline, and 3-hydroxyproline; and J is
an a-aminoaliphatic carboxylic acid; a has an average value of
about 1 to about 5; b has an average value of about 3 to about 20;
c is 1 to 10; and d is 0 to 3.
[0049] In various embodiments including "J" in the relevant
formula, J is an .alpha.-aminoaliphatic carboxylic acid having four
to six carbons, inclusive. In other variations, J is an
.alpha.-aminoaliphatic carboxylic acid having six or more carbons,
inclusive. In yet other variations, J is selected from the group
consisting of a-aminobutanoic acid, .alpha.-aminopentanoic acid,
.alpha.-amino-2-methylpropanoic acid, and a-aminohexanoic acid.
[0050] In certain embodiments, surfactant polypeptides of the
present invention comprise a sequence having including a sequence
having alternating groupings of amino acid residues as represented
by the formula: (Z.sub.aU.sub.b).sub.cZ.sub.d wherein Z is an amino
acid residue independently selected from the group consisting of R,
D, E, and K; and U is an amino acid residue independently selected
from the group consisting of V, I, L, C, Y and F; from the group
consisting of V, I, L, C and F; or from the group consisting of L
and C; a has an average value of about 1 to about 5; b has an
average value of about 3 to about 20; c is 1 to 10; and d is 0 to
3.
[0051] In the foregoing formulas, Z and U, Z and J, B and U, and B
and J are amino acid residues that, at each occurrence, are
independently selected. In addition, in each of the aforementioned
formulae, a generally has an average value of about 1 to about 5; b
generally has an average value of about 3 to about 20; c is 1 to
10; and d is 0 to 3.
[0052] In certain embodiments, Z and B are charged amino acid
residues. In other preferred embodiments, Z and B are hydrophilic
or positively charged amino acid residues. In one variation, Z is
preferably selected from the group consisting of R, D, E and K. In
a related embodiment, Z is preferably selected from the group
consisting of R and K. In yet another preferred embodiment, B is
selected from the group consisting of H, 5-hydroxylysine,
4-hydroxyproline, and 3-hydroxyproline. In one preferred
embodiment, B is H. In another preferred embodiment, B is a
collagen constituent amino acid residue and is selected from the
group consisting of 5-hydroxylysine, (.delta.-hydroxylysine),
4-hydroxyproline, and 3-hydroxyproline.
[0053] In certain embodiments, U and J are, preferably, uncharged
amino acid residues. In another preferred embodiment, U and J are
hydrophobic amino acid residues. In one embodiment, U is preferably
selected from the group consisting of V, I, L, C, Y, and F. In
another preferred embodiment, U is selected from the group
consisting of V, I, L, C, and F. In yet another preferred
embodiment, U is selected from the group consisting of L and C. In
various preferred embodiments, U is L.
[0054] Similarly, in certain embodiments, B is an amino acid
preferably selected from the group consisting of H,
5-hydroxylysine, 4-hydroxyproline, and 3-hydroxyproline.
Alternatively, B can be selected from the group consisting of
collagen-derived amino acids, which includes 5-hydroxylysine,
4-hydroxyproline, and 3-hydroxyproline.
[0055] In certain embodiments, charged and uncharged amino acids
are selected from groups of modified amino acids. For example, in
one preferred embodiment, a charged amino acid is selected from the
group consisting of citrulline, homoarginine, or omithine, to name
a few examples. Similarly, in various preferred embodiments, the
uncharged amino acid is selected from the group consisting of
.alpha.-aminobutanoic acid, .alpha.-aminopentanoic acid,
.alpha.-amino-2-methylpropanoic acid, and .alpha.-aminohexanoic
acid.
[0056] In certain embodiments of the present invention, items "a",
"b", "c" and "d" are numbers which indicate the number of charged
or uncharged residues (or hydrophilic or hydrophobic residues). In
various embodiments, "a" has an average value of about 1 to about
5, preferably about 1 to about 3, more preferably about 1 to about
2, and even more preferably, 1.
[0057] In various embodiments, "b" has an average value of about 3
to about 20, preferably about 3 to about 12, more preferably about
3 to about 10, even more preferably in the range of about 4-8. In
one preferred embodiment, "b" is about 4.
[0058] In various embodiments, "c" is 1 to 10, preferably 2 to 10,
more preferably in the range of 3-8 or 4-8, and even more
preferably 3 to 6. In one preferred embodiment, "c" is about 4.
[0059] In various embodiments, "d" is 0 to 3 or 1 to 3. In one
preferred embodiment, "d" is 0 to 2 or 1 to 2; in another preferred
embodiment, "d" is 1.
[0060] By stating that an amino acid residue is independently
selected, it is meant that at each occurrence, a residue from the
specified group is selected. That is, when "a" is 2, for example,
each of the hydrophilic residues represented by Z will be
independently selected and thus can include RR, RD, RE, RK, DR, DD,
DE, DK, and the like. By stating that "a" and "b" have average
values, it is meant that although the number of residues within the
repeating sequence (e.g., Z.sub.aU.sub.b) can vary somewhat within
the peptide sequence, the average values of "a" and "b" would be
about 1 to about 5 and about 3 to about 20, respectively.
[0061] For example, using the formula (Z.sub.aU.sub.b).sub.cZ.sub.d
for the peptide designated "KL8" in Table 2 below, the formula can
be rewritten as K.sub.1L.sub.8K.sub.1L.sub.8K.sub.1L.sub.2, wherein
the average value of "b" is six [i.e.,(8+8+2)/3=6], c is three and
d is zero.
[0062] Polypeptides of the present invention can also be subject to
various changes, such as insertions, deletions and substitutions,
either conservative or non-conservative, where such changes provide
for certain advantages in their use.
[0063] Additional residues can be added at either terminus of a
polypeptide of the present invention, such as for the purpose of
providing a "linker" by which such a polypeptide can be
conveniently affixed to a label or solid matrix, or carrier.
Labels, solid matrices and carriers that can be used with the
polypeptides of this invention are known in the art.
[0064] Amino acid residue linkers are usually at least one residue
and can be 40 or more residues, more often 1 to 10 residues.
Typical amino acid residues used for linking are tyrosine,
cysteine, lysine, glutamic and aspartic acid, or the like. In
addition, a polypeptide sequence of this invention can differ from
the natural sequence by the sequence being modified by
terminal-NH.sub.2 acylation, e.g., acetylation, or thioglycolic
acid amidation, terminal-carboxlyamidation, e.g., ammonia,
methylamine, and the like.
[0065] In certain embodiments, exemplary SP-B polypeptide mimics
that can be used in the present invention include, but are not
limited to, those shown in the Table 2. TABLE-US-00002 TABLE 2
Pulmonary Surfactant Mimetic Peptides SEQ Designation.sup.1 ID NO
Amino Acid Residue Sequence KL4 1 KLLLLKLLLLKLLLLKLLLLK DL4 2
DLLLLDLLLLDLLLLDLLLLD RL4 3 RLLLLRLLLLRLLLLRLLLLR RL8 4
RLLLLLLLLRLLLLLLLLRLL R2L7 5 RRLLLLLLLRRLLLLLLLRRL 6
RLLLLCLLLRLLLLLCLLLR 7 LLLLLCLLLRLLLLCLLLRLL 8
RLLLLCLLLRLLLLCLLLRLLLLCLLLR DLLLDLLLDLLLDLLLDLLLD RCL1 9
RLLLLCLLLRLLLLCLLLR RCL2 10 RLLLLCLLLRLLLLCLLLRLL RCL3 11
RLLLLCLLLRLLLLCLLLRLLLLCLLLR KL8 12 KLLLLLLLLKLLLLLLLLKLL KL7 13
KKLLLLLLLKKLLLLLLLKKL .sup.1The designation is an abbreviation for
the indicated amino acid residue sequence.
[0066] The present invention contemplates a variety of surfactant
molecules, including proteins, polypeptides, and molecules
including amino acid residues, as well as a variety of surfactant
compositions. A wide variety of other molecules, including uncommon
but naturally occurring amino acids, metabolites and catabolites of
natural amino acids, substituted amino acids, and amino acid
analogs, as well as amino acids in the "D" configuration, are
useful in molecules and compositions of the present invention. In
addition, "designed" amino acid derivatives, analogs and mimics are
also useful in various compounds, compositions and methods of the
present invention, as well as polymers including backbone
structures composed of non-amide linkages.
[0067] For example, in addition to the L-amino acids, amino acid
metabolites such as homoarginine, citrulline, omithine, and
a-aminobutanoic acid are also useful in pulmonary surfactants.
Thus, in the various formulas described above, "Charged", Z, or B
can comprise homoarginine, citrulline, or omithine, as well as a
variety of other molecules as identified herein. Similarly, J can
comprise .alpha.-amrinobutanoic acid (also known as
.alpha.-aminobutyric acid), .alpha.-aminopentanoic acid,
.alpha.-aminohexanoic acid, and a variety of other molecules
identified herein.
[0068] Further, substituted amino acids which are not generally
derived from proteins, but which are known in nature, are useful as
disclosed herein, include the following examples: L-canavanine;
1-methyl-L-histidine; 3-methyl-L-histidine; 2-methyl L-histidine;
.alpha., .epsilon.-diaminopimelic acid (L form, meso form, or
both); sarcosine; L-omithine betaine; betaine of histidine
(herzynine); L-citrulline; L-phosphoarginine; D-octopine;
o-carbamyl-D-serine; .gamma.-aminobutanoic acid; and .beta.-lysine.
D-amino acids and D-amino acid analogs, including the following,
are also useful in proteins, peptides and compositions of the
present invention: D-alanine, D-serine, D-valine, D-leucine,
D-isoleucine, D-alloisoleucine, D-phenylalanine, D-glutamic acid,
D-proline, and D-allohydroxyproline, to name some examples. The
foregoing can also be used in surfactant molecules according to the
present invention; particularly preferred for use accordingly are
those corresponding to the formula
{(Charged).sub.a(Uncharged).sub.b}.sub.c(Charged).sub.d.
[0069] An extensive variety of amino acids, including metabolites
and catabolites thereof, can be incorporated into molecules which
display a surfactant activity. For example, molecules such as
ornithine, homoarginine, citrulline, and a-aminobutanoic acid are
useful components of molecules displaying surfactant activity as
described herein. Surfactant molecules according to the present
invention can also comprise longer straight-chain molecules;
.alpha.-aminopentanoic acid and .alpha.-aminohexanoic acid are two
additional examples of such useful molecules.
[0070] It should also be appreciated that the present invention
encompasses a wide variety of modified amino acids, including
analogs, metabolites, catabolites, and derivatives, irrespective of
the time or location at which modification occurs. In essence, one
can place modified amino acids into three categories: (1)
catabolites and metabolites of amino acids; (2) modified amino
acids generated via posttranslational modification (e.g.,
modification of side chains); and (3) modifications made to amino
acids via non-metabolic or non-catabolic processes (e.g., the
synthesis of modified amino acids or derivatives in the
laboratory).
[0071] The present invention also contemplates that one can readily
design side chains of the amino acids of residue units that include
longer or shortened side chains by adding or subtracting methylene
groups in either linear, branched chain, or hydrocarbon or
heterocyclic ring arrangements. The linear and branched chain
structures can also contain non-carbon atoms such as S, O, or N.
Fatty acids can also be useful constituents of surfactant molecules
herein. The designed side chains can terminate with (R') or without
(R) charged or polar group appendages.
[0072] In addition, analogs, including molecules resulting from the
use of different linkers, are also useful as disclosed herein.
Molecules with side chains linked together via linkages other than
the amide linkage e.g., molecules containing amino acid side chains
or other side chains (R- or R'-) wherein the components are linked
via carboxy- or phospho-esters, ethylene, methylene, ketone or
ether linkages, to name a few examples, are also useful as
disclosed herein. In essence, any amino acid side chain, R or R'
group-containing molecule can be useful as disclosed herein, as
long as the molecule includes alternating hydrophilic and
hydrophobic residues (i.e., component molecules) and displays
surfactant activity as described herein.
[0073] The present invention also contemplates molecules comprising
peptide dimers joined by an appropriate linker, e.g., peptide
dimers linked by cystine molecules. Such linkers or bridges can
thus cross-link different polypeptide chains, dimers, trimers, and
the like. Other useful linkers which can be used to connect peptide
dimers and/or other peptide multimers include those listed above
e.g., carboxy- or phospho-ester, ethylene, methylene, ketone or
ether linkages, to name a few examples.
[0074] While it is appreciated that many useful polypeptides
disclosed herein comprise naturally-occurring amino acids in the
"L" form which are joined via peptide linkages, it should also be
understood that molecules including amino acid side chain analogs,
non-amide linkages (e.g., differing backbones) can also display a
significant surfactant activity and can possess other advantages,
as well. For example, if it is desirable to construct a molecule
(e.g., for use in a surfactant composition) that is not readily
degraded, one may wish to synthesize a polypeptide molecule
comprising a series of D-amino acids. Molecules comprising a series
of amino acids linked via a "retro" backbone, i.e., a molecule that
has internal amide bonds constructed in the reverse direction of
carboxyl terminus to amino terminus, are also more difficult to
degrade and can thus be useful in various applications, as
described herein. For example, the following illustrates an
exemplary molecule with a "retro" bond in the backbone:
##STR1##
[0075] In another variation, one may wish to construct a molecule
that adopts a more "rigid" conformation; one means of accomplishing
this would be to add methyl or other groups to the a carbon atom of
the amino acids.
[0076] As noted above, other groups besides a CH.sub.3 group can be
added to the a carbon atom, that is, surfactant molecules of the
present invention are not limited to those incorporating a CH.sub.3
at the a carbon alone. For example, any of the side chains and
molecules described above can be substituted for the indicated
CH.sub.3 group at the a carbon component.
[0077] As used herein, the terms "analogs" and "derivatives" of
polypeptides and amino acid residues are intended to encompass
metabolites and catabolites of amino acids, as well as molecules
which include linkages, backbones, side-chains or side-groups which
differ from those ordinarily found in what are termed
"naturally-occurring" L-form amino acids. (The terms "analog" and
"derivative" can also conveniently be used interchangeably herein.)
Thus, D-amino acids, molecules which mimic amino acids and amino
acids with "designed" side chains (i.e., that can substitute for
one or more amino acids in a molecule having surfactant activity)
are also encompassed by the terms "analogs" and "derivatives"
herein.
[0078] A wide assortment of useful surfactant molecules, including
amino acids having one or more extended or substituted R or R'
groups, is also contemplated by the present invention. Again, one
of skill in the art should appreciate from the disclosures that one
can make a variety of modifications to individual amino acids, to
the linkages, and/or to the chain itself, which modifications will
produce molecules falling within the scope of the present
invention, as long as the resulting molecule possesses surfactant
activity as described herein.
[0079] In certain methods of the present invention, a pulmonary
surfactant comprises one or more lipids. In these embodiments, the
surfactant composition can comprise, for example, from as little as
about 0.05 to 100% weight percent lipid, so long as the resulting
composition has surfactant activity. By weight percent is meant the
percentage of a compound by weight in a composition by weight.
Thus, a composition having 50 weight percent lipid contains, for
example, 50 grams lipids per 100 grams total composition. The term
"lipid" as used herein refers to a naturally occurring, synthetic
or semi-synthetic (i.e., modified natural) compound which is
generally amphipathic. The lipids typically comprise a hydrophilic
component and a hydrophobic component. Exemplary lipids include,
but are not limited, phospholipids, fatty acids, fatty alcohols,
neutral fats, phosphatides, oils, glycolipids, surface-active
agents (surfactants), aliphatic alcohols, waxes, terpenes and
steroids. The phrase semi-synthetic (or modified natural) denotes a
natural compound that has been chemically modified in some fashion.
Preferably, the lipids of are fatty acids, alcohols, esters and
ethers thereof, fatty amines, or combinations thereof.
[0080] Examples of phospholipids include native and/or synthetic
phospholipids. Phospholipids that can be used include, but are not
limited to, phosphatidylcholines, phospatidylglycerols,
phosphatidylethanolamines, phosphatidylserines, phosphatidic acids,
phosphatidylinositols, sphingolipids, diacylglycerides,
cardiolipin, ceramides, cerebrosides and the like. Exemplary
phospholipids include, but are not limited to, dipalmitoyl
phosphatidylcholine (DPPC), dilauryl phosphatidylcholine (DLPC)
(C12:0), dimyristoyl phosphatidylcholine (DMPC) (C14:0), distearoyl
phosphatidylcholine (DSPC), diphytanoyl phosphatidylcholine,
nonadecanoyl phosphatidylcholine, arachidoyl phosphatidylcholine,
dioleoyl phosphatidylcholine (DOPC) (C18:1), dipalmitoleoyl
phosphatidylcholine (C 16:1), linoleoyl phosphatidylcholine (C
18:2), myristoyl palmitoyl phosphatidylcholine (MPPC), steroyl
myristoyl phosphatidylcholine (SMPC), steroyl palmitoyl
phosphatidylcholine (SPPC), palmitoyloleoyl phosphatidylcholine
(POPC), palmitoyl palmitooleoyl phosphatidylcholine (PPoPC),
dipalmitoyl phosphatidylethanolamine (DPPE), palmitoyloleoyl
phosphatidylethanolamine (POPE), dioleoylphosphatidylethanolamine
(DOPE), dimyristoyl phosphatidylethanolamine (DMPE), distearoyl
phosphatidylethanolamine (DSPE), dioleoyl phosphatidylglycerol
(DOPG), palmitoyloleoyl phosphatidylglycerol (POPG), dipalmitoyl
phosphatidylglycerol (DPPG), dimyristoyl phosphatidylglycerol
(DMPG), distearoyl phosphatidylglycerol (DSPG),
dimyristoylphosphatidylserine (DMPS), distearoylphosphatidylserine
(DSPS), palmitoyloleoyl phosphatidylserine (POPS), soybean
lecithin, egg yolk lecithin, sphingomyelin, phosphatidylinositols,
diphosphatidylglycerol, phosphatidylethanolamine, phosphatidic
acids, and egg phosphatidylcholine (EPC).
[0081] Examples of fatty acids and fatty alcohols include, but are
not limited to, sterols, palmitic acid, cetyl alcohol, lauric acid,
myristic acid, stearic acid, phytanic acid, dipamlitic acid, and
the like. Preferably, the fatty acid is palmitic acid and
preferably the fatty alcohol is cetyl alcohol.
[0082] Examples of fatty acid esters include, but are not limited
to, methyl palmitate, ethyl palmitate, isopropyl palmitate,
cholesteryl palmitate, palmityl palmitate sodium palmitate,
potassium palmitate, tripalmitin, and the like.
[0083] An example of a semi-synthetic or modified natural lipid is
any one of the lipids described above which has been chemically
modified. The chemical modification can include a number of
modifications; however, a preferred modification is the conjugation
of one or more polyethylene glycol (PEG) groups to desired portions
of the lipid. Polyethylene glycol (PEG) has been widely used in
biomaterials, biotechnology and medicine primarily because PEG is a
biocompatible, nontoxic, nonimmunogenic and water-soluble polymer.
Zhao and Harris, ACS Symposium Series 680: 458-72, 1997. In the
area of drug delivery, PEG derivatives have been widely used in
covalent attachment (i.e., "PEGylation") to proteins to reduce
immunogenicity, proteolysis and kidney clearance and to enhance
solubility. Zalipsky, Adv. Drug Del. Rev. 16: 157-82, 1995.
[0084] Lipids that have been conjugated with PEG are referred to
herein as "PEG-lipids." Preferably, when PEG-lipids are used, they
are present in alcohols and/or aldehydes.
[0085] The pulmonary surfactant can comprise other excipients,
including, but not limited to, various sugars such as dextrose,
fructose, lactose, maltose, mannitol, sucrose, sorbitol, trehalose,
and the like, surfactants such as, for example, polysorbate-80,
polysorbate-20, sorbitan trioleate, tyloxapol and the like,
polymers such as PEG, dextran and the like, salts such as NaCl,
CaCl.sub.2 and the like, alcohols, such as cetyl alcohol, and
buffers.
[0086] Exemplary surfactant compositions can be prepared using
methods known in the art. For example, in certain embodiments, an
exemplary surfactant composition comprising lipids and
polypetptides can be prepared by admixing a solution of a
surfactant polypeptide with a suspension of liposomes, or by
admixing the surfactant polypeptide with a suspension of liposomes,
or by admixing the surfactant polypeptide and phospholipids
directly in the presence of organic solvent.
[0087] Preferably, the pulmonary surfactant comprises phospholipids
and free fatty acids or fatty alcohols, e.g., DPPC (dipalmitoyl
phosphatidylcholine), POPG (palmitoyl-oleyl phosphatidylglycerol)
and palmitic acid (PA). See, for example, U.S. Pat. No. 5,789,381
the disclosure of which is incorporated herein by reference in its
entirety and for all purposes.
[0088] In certain preferred embodiments, the pulmonary surfactant
is lucinactant or another pulmonary surfactant formulation
comprising the synthetic surfactant protein KLLLLKLLLLKLLLLKLLLL
(KL4; SEQ ID NO:1). Lucinactant, is a combination of DPPC, POPG,
palmitic acid (PA) and the KL4 peptide (weight ratio of
approximately 7.5:2.5:1.35:0.267). In certain embodiments, the drug
product is formulated at concentrations of, for example, 10, 20,
and 30 mg/ml of phospholipid content. In certain other embodiments,
the drug product is formulated at greater concentrations, e.g., 40,
60, 90, 120 or more mg/ml phospholipid content, with concomitant
increases in KL4 concentration.
[0089] Any pulmonary surfactant currently in use, or hereafter
developed for use in respiratory distress system and other
pulmonary conditions, is suitable for use in the present invention.
These include naturally occurring and synthetic pulmonary
surfactant. Synthetic PS, as used herein, refers to both
protein-free lung surfactants and pulmonary surfactants comprising
synthetic peptides, including peptide mimetics of naturally
occurring surfactant protein. Current PS products include, but are
not limited to, lucinactant (Surfaxin.RTM., Discovery Laboratories,
Inc., Warrington, Pa.), bovine lipid surfactant (BLES.RTM., BLES
Biochemicals, Inc. London, Ont), calfactant (Infasurf.RTM., Forest
Pharmaceuticals, St. Louis, Mo.), natural bovine surfactant
(Alveofact.RTM., Thomae, Germany), bovine surfactant (Surfactant
TA.RTM., Tokyo Tanabe, Japan), poractant alfa (Curosurf.RTM.,
Chiesi Farmaceutici SpA, Parma, Italy), pumactant (Alec.RTM.,
Britannia Pharmaceuticals, UK), beractant (Survanta.RTM., Abbott
Laboratories, Inc., Abbott Park, Ill.) and colfosceril palmitate
(Exosurf.RTM., GlaxoSmithKline, plc, Middlesex, U.K.). In a
preferred embodiment, the PS is lucinactant or another PS
formulation comprising the synthetic surfactant protein
KLLLLKLLLLKLLLLKLLLL (KL4; SEQ ID NO:1).
[0090] The treatment regimens described herein can be combined with
other respiratory therapies. In certain embodiments, PS
administration is performed on infants who are intubated and
maintained on ventilation, either conventional ventilation or high
frequency ventilation, for a period of time or for the entire
duration of the PS treatment.
[0091] In other embodiments, alternative modes of administration
can be utilized, as well as alternative PS formulations. For
example, PS can be formulated for aerosolization (nebulization) and
administered via nasal CPAP, nasal or naso-pharyngeal prongs in
combination with low-flow oxygen, or via face mask or oxygen
hood.
[0092] In certain embodiments, aerosolized pulmonary surfactant can
be administered as provided in copending U.S. application Ser. No.,
11/130,783, filed May 17, 2005, incorporated herein by reference in
its entirety and for all purposes. Administration can be in
conjunction with another noninvasive pulmonary respiratory therapy
involving the administration of positive airway pressure. The term
"noninvasive pulmonary respiratory therapy" refers to respiratory
therapy which does not use mechanical ventilation and can include
CPAP, bilevel positive airway pressure (BiPAP), synchronized
intermittent mandatory ventilation (SIMV), and the like. The
employment of such therapies involves the use of various
respiratory gases, as would be appreciated by the skilled artisan.
Respiratory gases used for noninvasive pulmonary respiratory
therapy are sometimes referred to herein as "CPAP gas," "CPAP air,"
"nCPAP", "ventilation gas," "ventilation air," or simply "air."
However, those terms are intended to include any type of gas
normally used for noninvasive pulmonary respiratory therapy,
including but not limited to gases and gaseous combinations listed
above for use as the conditioning gas. In certain embodiments, the
gas used for noninvasive pulmonary respiratory therapy is the same
as the conditioning gas. In other embodiments, the respective gases
are different from one another.
[0093] In certain embodiments, the pulmonary delivery methods of
this invention are employed in conjunction with CPAP. It has been
shown that use of CPAP allows for an increase in functional
residual capacity and improved oxygenation. The larynx is dilated
and supraglottic airway resistance is normal. There is also an
improvement of the synchrony of respiratory thoracoabdominal
movements and enhanced Hering-Breuer inflation reflex following
airway occlusion. CPAP has been shown to be useful in treating
various conditions such as sleep apnea, snoring, ARDS, IRDS, and
the like.
[0094] In order to effect administration of CPAP, a pressure source
and a delivery device or delivery apparatus are required.
CPAP-producing airflow is typically generated in the vicinity of
the nasal airways by converting kinetic energy from a jet of fresh
humidified gas into a positive airway pressure. A continuous flow
rate of breathing gas of about 5 to about 12 liters/minute
generates a corresponding CPAP of about 2 to about 10 cm H.sub.2O.
Various modifications can be applied to the CPAP system which
include sensors that can individualize the amount of pressure based
on the patient's need.
[0095] Typically, flow rates and pressures suitable for achieving
CPAP are based upon the characteristics of the patient being
treated. Suitable flow rates and pressures can be readily
calculated by the attending clinician. The present invention
encompasses the use of a variety of flow rates for the ventilating
gas, including low, moderate and high flow rates. Alternatively,
the aerosol can be supplied without added positive pressure, i.e.,
without CPAP as a simultaneous respiratory therapy.
[0096] Preferably, the CPAP-generating air flow being delivered to
the patient has a moisture level which will prevent unacceptable
levels of drying of the lungs and airways. Thus, the
CPAP-generating air is often humidified by bubbling through a
hydrator, or the like to achieve a relative humidity of preferably
greater that about 70%. More preferably, the humidity is greater
than about 85% and still more preferably 98%.
[0097] A suitable source of CPAP-inducing airflow is the underwater
tube CPAP (underwater expiratory resistance) unit. This is commonly
referred to as a bubble CPAP.
[0098] Another preferred source of pressure is an expiratory flow
valve that uses variable resistance valves on the expiratory limb
of CPAP circuits. This is typically accomplished via a
ventilator.
[0099] Another preferred source is the Infant Flow Driver or "IFD"
(Electro Medical Equipment, Ltd., Brighton, Sussex, UK). IFD
generates pressure at the nasal level and employs a conventional
flow source and a manometer to generate a high pressure supply jet
capable of producing a CPAP effect. It is suggested in the
literature that the direction of the high pressure supply jet
responds to pressures exerted in the nasal cavity by the patient's
efforts and this reduces variations in air pressure during the
inspiration cycle.
[0100] Other CPAP systems including those that contain similar
features to systems just discussed are also contemplated by the
present invention.
[0101] The aerosol stream generated in accordance aerosolized
delivery is preferably delivered to the patient via a nasal
delivery device which can involve, for example masks, single nasal
prongs, binasal prongs, nasopharyngeal prongs, nasal cannulae and
the like. The delivery device is chosen so as to minimize trauma,
maintain a seal to avoid waste of aerosol, and minimize the work
the patient must perform to breathe.
[0102] When used as an aerosol preparation, the surfactant
composition can be supplied in finely divided form, optionally in
combination with a suitable propellant. Useful propellants are
typically gases at ambient conditions and are condensed under
pressure including, for example, lower alkanes and fluorinated
alkanes, such as freon. In certain embodiments wherein the
surfactant composition is delivered as an aerosol, the aerosol can
be packaged in a suitable container under pressure.
[0103] Suitable dosage of the surfactant, whether aerosolized or
delivered as a liquid or dry powder will be dependent on the
patient's age and severity of the disorder and will be readily
ascertainable by the attending clinician. The actual dosage of
pulmonary surfactant will of course vary according to factors such
as the extent of exposure and particular status of the subject
(e.g., the subject's age, size, fitness, extent of symptoms,
susceptibility factors, and the like). By "effective dose" herein
is meant a dose that produces effects for which it is
administered.
[0104] When the surfactant is supplied to prematurely born infants
as a liquid, an aliquot of the surfactant composition is delivered,
preferably by intratracheal instillation, to provide an effective
dose of surfactant in the lungs of the treated patient. Preferably,
a single surfactant dose ranges from, for example, about 20 to
about 300 mg total phospholipidid (TPL)/kg, more preferably from
about 60 to about 175 mg TPL/kg. It being understood, of course,
that the exact dose of surfactant will depend upon factors such as
the age and condition of the patient, the severity of the condition
being treated, and other factors well within the skill of the
attending clinician. In certain embodiments wherein the surfactant
composition is delivered as an aerosol, such as disclosed in
co-pending U.S. application Ser. No. 11/130,783, filed May 17,
2005, the effective dose of lung surfactant can be, for example,
from about 1 mg TPL/kg surfactant to about 1000 mg TPL/kg
surfactant, preferably from about 2 mg TPL/kg surfactant to about
175 mg TPL/kg surfactant. In certain embodiments wherein the
surfactant composition is delivered as a dry powder formulation,
the effective dose of lung surfactant can be, for example, from
about 1 mg TPL/kg surfactant to about 1000 mg or more TPL/kg
surfactant, preferably from about 2 mg TPL/kg surfactant to about
175 mg TPL/kg surfactant. Other methods of delivery include lavage,
lung wash, and the like. When so employed dose ranges are well
within the skill of one in the art.
[0105] The frequency of dosing can vary, but typically is once
every 2-3 days. In other embodiments, the patient is dosed more
frequently, e.g., every 6-8 hours, twice daily, or once daily, or
less frequently, e.g., twice weekly or even once weekly. In other
embodiments, the patient can be dosed more frequently early in the
treatment regimen, and with decreasing frequency later in the
treatment regimen, e.g., once every other day for one week,
followed by twice weekly until the end of the treatment period.
Depending on the dosage form, e.g., aerosol or dry powder as
compared with liquid instillate, the patient can be dosed
continuously for part or all of the treatment period.
[0106] In other embodiments, the infant can be treated with other
therapeutic, prophylactic or complementary agents, such as
steroids, nitric oxide, antioxidants or reactive oxygen scavengers,
bronchodilators, diuretics, antimicrobial or anti-infective agents,
anti-hypertensive agents, or anti-inflammatory agents (e.g.,
PLA.sub.2 inhibitors, protease or elastase inhibitors, PDE-4
inhibitors, to name a few), as would be appreciated by one of skill
in the art. Such treatment can include concomitant administration
of the PS with other therapeutic, prophylactic or complementary
agents. Concomitant administration can involve concurrent (i.e. at
the same time), prior, or subsequent administration of the
complementary agent with respect to the administration of the
pulmonary surfactant. When administered in combination, each
component can be administered at the same time or sequentially in
any order at different points in time. Thus, each component can be
administered separately but sufficiently closely in time so as to
provide the desired therapeutic effect. Concomitant administration
of a PS with other therapeutic, prophylactic or complementary
agents means administration of the PS and other agents at such time
that both will have a therapeutic effect. A person of ordinary
skill in the art, would have no difficulty determining the
appropriate timing, sequence and dosages of administration for
particular drugs of the present invention.
[0107] The following examples are provided to describe the
invention in greater detail. Thy are intended to illustrate, not to
limit, the invention.
EXEMPLARY EMBODIMENTS
Example 1
Protocol for Administration of Lucinactant to Premature Infants at
Risk for Bronchopulmonary Dysplasia
[0108] This example provides a protocol for administration of
lucinactant to very low birthweight (VLBW) premature infants who
have been intubated and received surfactants for the prevention or
treatment of respiratory distress syndrome (RDS). The protocol has
been used in a clinical trial to assess the safety and efficacy of
lucinactant in VLBW infants at risk for developing BPD.
[0109] Two dosing regimens of lucinactant (90 mg/kg birthweight or
175 mg/kg birthweight) were utilized. Infants born with a
birthweight 600 to 900 grams and who remained intubated at day of
life (DOL) 3 in anticipation of worsening lung disease were
treated. Treatment was administered on days 3, 5, 7, 10 and 14, if
the infant remained intubated. It should be noted that Day 1 (or
DOL 1) is the day on which Time 0 (time of birth) occurs and DOL 2,
3, and so on, begin at 00:00 (midnight) each subsequent day
following Time 0.
[0110] Lucinactant was administered in accordance with
manufacturer's instructions. Briefly, administration of lucinactant
is by syringe typically attached to an end-hole catheter passed
through a Bodai valve or equivalent so that that the catheter tip
terminates at the distal end of the endotracheal tube. The infant
is placed in a head-up left lateral decubitus position and slowly
administered half the syringe volume. After allowing a brief
recovery period, the infant is placed in the right lateral
decubitus position and the remaining contents of the syringe are
administered. The dose was administered in quarters (alternating
left-right decubitus positioning) if determined to be
necessary.
[0111] Efficacy of the treatment protocol was determined by making
the following assessments: (1) proportion of infants remaining on
mechanical ventilation or oxygen over time; (2) incidence of death
or BD at 28 days and 36 weeks post-menstrual age (post-conception);
(3) AUC day 3-28 fraction of inspired oxygen (FiO.sub.2) and mean
airway pressure; (4) pulmonary compliance as assessed by ventilator
derived pressure-volume loops pre, 6 and 24 hours post dose; and
(5) surrogate measures of efficacy including assessment of surface
tension lowering properties of tracheal aspirates and concentration
of growth factors and inflammatory mediators in tracheal aspirates
collected as a part of routine neonatal intensive care.
Example 2
Protocol for Administration of Lucinactant Delivered as an Aerosol
Via nCPAP for the Prevention of RDS in Premature Infants
[0112] This example provides a protocol for administration of
lucinactant as an aerosol via nCPA to premature infants. This
protocol has been used in a pilot phase 2, open study to evaluate
the feasibility, safety, and tolerability of lucinactant delivered
as an aerosol via nCPAP for the prevention of RDS in premature
neonates.
[0113] Lucinactant was administered using an approved vibrating
machine device (Aeroneb-Pro.RTM. or equivalent) and delivered via
nCPAP within 30 minutes of birth. In a first treatment group, 20
mg/ml of lucinactant was administered within the first 30 minutes
of life continually over three hours. Up to three retreatments were
permitted over a 48 hour period, with each treatment separated by
at least 3 hours (from end of previous treatment). In a second
treatment group, 20 mg/ml of lucinactant was administered within
the first 30 minutes of life continually over three hours. Up to
three retreatments were permitted over a 48 hour period, with each
treatment separated by at least one hours (from end of previous
treatment).
[0114] Qualified premature neonates were sequentially enrolled and
stratified by gestational age (stratum 1:30-32 completed weeks
followed by stratum 2:28-29 completed weeks) into the first
treatment regimen group (3 hours on aerosol treatment/3 hours off
aerosol treatment) and received aerosolized lucinactant via nCPAP.
Safety and tolerability data were evaluated after enrollment of
every five neonates. Once enrollment in the first treatment group
was completed, neonates were sequentially enrolled and stratified
into the second treatment group (3 hours on aerosol treatment/1
hours off aerosol treatment). All neonates enrolled were evaluated
through 28 days of age.
[0115] All 17 neonates experienced at least 1 adverse effect
regardless of relationship. A total of 83 adverse effects were
reported; of these adverse effects, 8 (47.1%) were considered
related to study drug, 2 (11.8%) were considered related to the
device, and 6 (35.3%) were considered related to both study drug
and the device. The most common adverse effects, regardless of
relationship to study treatment were apnea (16/17, 94.1%), oxygen
saturation decreased (12/17, 70.6%), patent ductus arteriosus
(6/17, 35.3%), hypocalcemia (5/17, 29.4%). A total of 5 serious
adverse effects were reported during the course of the study. Two
of the serious adverse effects were considered related to the
device. No deaths were occurred during this study.
[0116] The study showed that it is feasible to deliver lucinactant
via nCPAP and the treatment was generally safe and well tolerated.
Key observations included that 15 of the 17 neonates had no
evidence of BPD at day 28.
[0117] From the foregoing description, various modifications and
changes in the compositions and methods will occur to those skilled
in the art. All such modifications coming within the scope of the
appended claims are intended to be included therein. Each recited
range includes all combinations and sub-combinations of ranges, as
well as specific numerals contained therein.
[0118] All publications and patent documents cited above are hereby
incorporated by reference in their entirety for all purposes to the
same extent as if each were so individually denoted.
[0119] Although the foregoing invention has been described in
detail by way of example for purposes of clarity of understanding,
it will be apparent to the artisan that certain changes and
modifications are comprehended by the disclosure and can be
practiced without undue experimentation within the scope of the
appended claims, which are presented by way of illustration not
limitation.
Sequence CWU 1
1
13 1 21 PRT Artificial Sequence Synthetic Construct 1 Lys Leu Leu
Leu Leu Lys Leu Leu Leu Leu Lys Leu Leu Leu Leu Lys 1 5 10 15 Leu
Leu Leu Leu Lys 20 2 21 PRT Artificial Sequence Synthetic Construct
2 Asp Leu Leu Leu Leu Asp Leu Leu Leu Leu Asp Leu Leu Leu Leu Asp 1
5 10 15 Leu Leu Leu Leu Asp 20 3 21 PRT Artificial Sequence
Synthetic Construct 3 Arg Leu Leu Leu Leu Arg Leu Leu Leu Leu Arg
Leu Leu Leu Leu Arg 1 5 10 15 Leu Leu Leu Leu Arg 20 4 21 PRT
Artificial Sequence Synthetic Construct 4 Arg Leu Leu Leu Leu Leu
Leu Leu Leu Arg Leu Leu Leu Leu Leu Leu 1 5 10 15 Leu Leu Arg Leu
Leu 20 5 21 PRT Artificial Sequence Synthetic Construct 5 Arg Arg
Leu Leu Leu Leu Leu Leu Leu Arg Arg Leu Leu Leu Leu Leu 1 5 10 15
Leu Leu Arg Arg Leu 20 6 20 PRT Artificial Sequence Synthetic
Construct 6 Arg Leu Leu Leu Leu Cys Leu Leu Leu Arg Leu Leu Leu Leu
Leu Cys 1 5 10 15 Leu Leu Leu Arg 20 7 21 PRT Artificial Sequence
Synthetic Construct 7 Leu Leu Leu Leu Leu Cys Leu Leu Leu Arg Leu
Leu Leu Leu Cys Leu 1 5 10 15 Leu Leu Arg Leu Leu 20 8 49 PRT
Artificial Sequence Synthetic Construct 8 Arg Leu Leu Leu Leu Cys
Leu Leu Leu Arg Leu Leu Leu Leu Cys Leu 1 5 10 15 Leu Leu Arg Leu
Leu Leu Leu Cys Leu Leu Leu Arg Asp Leu Leu Leu 20 25 30 Asp Leu
Leu Leu Asp Leu Leu Leu Asp Leu Leu Leu Asp Leu Leu Leu 35 40 45
Asp 9 19 PRT Artificial Sequence Synthetic Construct 9 Arg Leu Leu
Leu Leu Cys Leu Leu Leu Arg Leu Leu Leu Leu Cys Leu 1 5 10 15 Leu
Leu Arg 10 21 PRT Artificial Sequence Synthetic Construct 10 Arg
Leu Leu Leu Leu Cys Leu Leu Leu Arg Leu Leu Leu Leu Cys Leu 1 5 10
15 Leu Leu Arg Leu Leu 20 11 28 PRT Artificial Sequence Synthetic
Construct 11 Arg Leu Leu Leu Leu Cys Leu Leu Leu Arg Leu Leu Leu
Leu Cys Leu 1 5 10 15 Leu Leu Arg Leu Leu Leu Leu Cys Leu Leu Leu
Arg 20 25 12 21 PRT Artificial Sequence Synthetic Construct 12 Lys
Leu Leu Leu Leu Leu Leu Leu Leu Lys Leu Leu Leu Leu Leu Leu 1 5 10
15 Leu Leu Lys Leu Leu 20 13 21 PRT Artificial Sequence Synthetic
Construct 13 Lys Lys Leu Leu Leu Leu Leu Leu Leu Lys Lys Leu Leu
Leu Leu Leu 1 5 10 15 Leu Leu Lys Lys Leu 20
* * * * *